Neurosurgeons and the Treatment of Trigeminal Neuralgia

joshJoshua M. Rosenow, MD, FAANS, FACS
Director of Functional Neurosurgery, Northwestern University Feinberg School of Medicine

Chicago, IL

Trigeminal neuralgia (TN), also known as tic douloureux, sometimes is described as the most excruciating pain known to humanity. The pain typically involves the lower face and jaw, although sometimes it affects the area around the nose and above the eye. This intense, stabbing, electric shock-like pain is caused by irritation of the trigeminal nerve, which sends branches to the forehead, cheek and lower jaw. It usually is limited to one side of the face.

Neurosurgeons have always been at the forefront of TN treatment. While medical treatments such as diphenylhydantoin came along in the 1940s, followed by the prototypical TN drug carbamazepine in the 1960s, neurosurgeons had already developed multiple surgical procedures aimed at curing this disabling disease.

John M. Carnochan, MD had begun removing the trigeminal ganglion in the 1850s. Other surgeons, such as William Rose, Edmund Andrews and Victor Horsley, adopted this technique as well. The Hartley-Krause approach (named after Frank Hartley, MD and Fedor Krause, popularized in the 1890s, involved approaching and resecting the trigeminal ganglion without opening the cranial dura. William G. Spiller, MD and Charles Frazier, MD refined the procedure by only performing selective resection of the affected divisions of the nerve, with the hope of sparing the unaffected regions. Neurosurgeons adopted this as the standard surgical approach for TN, especially given the absence of any good medical therapy.

face painAt Johns Hopkins in the 1920s, Walter E. Dandy, MD had begun to revolutionize the approach to the trigeminal nerve by opening the skull behind the ear and approaching the nerve at its exit point from the brainstem. This modification is one of the most pivotal in the history of TN treatment. While Dandy used this approach to perform partial cutting of the trigeminal nerve root, he had the opportunity to observe that many of the painful nerves were compressed by arteries. In multiple publications in the late 1920s and 1930s, he speculated about the presence of arterial compression as the cause of TN. His seminal publication in 1934 “Concerning the Cause of Trigeminal Neuralgia,” documented the high frequency of cases with neurovascular compression. This led to the popularization by Peter J. Jannetta, MD several decades later of microvascular decompression. This remarkably safe and effective procedure has become commonplace in the treatment of TN. Moreover, the recognition of vascular compression as playing a role in the etiology of TN has not only provided insights into the genesis of this disease but also into the origins of other disorders such as hemifacial spasm and glossopharyngeal neuralgia.

Neurosurgeons have also pioneered less invasive surgical treatments. Bernard J. Cosman, MS took advantage of the ability for radiofrequency energy passed through an electrode to generate heat and destroy tissue to selectively lesion branches of the trigeminal nerve to relieve pain. Later, neurosurgeon John F. “Sean” Mullan, MD used this same approach in placing a needle at the trigeminal ganglion to develop the balloon compression procedure that can more easily treat a wider distribution of facial pain without requiring the patient to be awake during the procedure.

In Sweden, Lars G. Leksell, MD created the Gamma Knife. This invention created an entirely new class of surgical treatment — stereotactic radiosurgery. Never before had physicians been able to so precisely target radiation without the surrounding tissues also receiving significant radiation exposure. This device now allowed neurosurgeons to deliver high doses of radiation to the trigeminal nerve root while sparing the adjacent, sensitive brain stem from significant radiation. This provided yet another option to patients suffering from TN who could not undergo other procedures or to whom other procedures were less attractive.

Neurosurgeons have continued to innovate over the years in the service of fighting facial pain. In recent years Kim J. Burchiel, MD, FAANS, has redefined how we discuss and diagnose facial pain, allowing neurosurgeons to help ensure that patients receive the correct treatment. For those patients with non-TN facial pain, neurosurgeons in Japan and Europe such as Takashi Tsubokawa, MD, PhD and Yves Keravel, MD have popularized cortical stimulation and Yoshio Hosobuchi, MD, John Adams, MD and Donald E. Richardson, MD in the United States, among others, have played roles in investigating the role of deep brain stimulation.

Neurosurgeons remain committed to providing the highest level of compassionate and timely care for patients suffering from facial pain. We will continue working diligently to bring new technology and scientific discoveries to patients in the hope of relieving them of this burden.

Editor’s note: The content of this post originally appeared on the American Association of Neurological Surgeon’s (AANS) website as part of their 2017 Neurosurgery Awareness Month on trigeminal neuralgia. During the month of September, we encourage everyone to join the conversation online by using the hashtag #painfacts.

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AANS Neurosurgeon Spotlight: September 2017 – The Enemy of Human Happiness: Pain

123AANS Neurosurgeon is the official socioeconomic publication of the American Association of Neurological Surgeons (AANS) and features information and analysis for contemporary neurosurgical practice. Topics covered relate to legislation, workforce issues and practice management as they affect the specialty of neurosurgery. The September 2017 edition of AANS Neurosurgeon explores the theme, “The Enemy of Human Happiness: Pain,” discussing the impact of pain on practice within the field for neurosurgeons, neurosurgical training and patients.

What are the ethical considerations when it comes to pain? How does this impact the education process for neurosurgeons-in-training? What impact does legislation have on patients, and how is the neurosurgeon’s responsibility defined? Without standard pain treatment practices, will future neurosurgeons be inadequately trained? These questions, along with many others, are answered throughout a number of articles in this publication.

Some highlights of the issue:

Elsewhere in the issue, readers can check out additional theme-related articles, as well as book reviews and updates from the Washington office via its “Washington Watch” column.

In addition to its regularly updated Twitter page, AANS Neurosurgeon also boasts Facebook page. Follow both social media accounts to read articles and stay current on the latest neurosurgical news.

Editor’s Note: During the month of September, we encourage everyone to join the conversation online by using the hashtag #painfacts.

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Global Pain Initiative: Changing the Way People with Pain are Treated

winfreeChristopher J. Winfree, MD, FAANS
Department of Neurological Surgery, Columbia University
New York, NY

Pain management in American is currently undergoing a renovation. In the early 2000s, it became apparent that undertreated chronic pain was a huge health care problem. The Affordable Care Act (ACA) commissioned a detailed investigation into the status of pain health care delivery in this country. Once problems were identified by the investigation, some major initiatives were established to correct many of these issues. Neurosurgery is an important stakeholder in this process and is part of the National Pain Foundation’s (NPF) Global Pain Initiative. This effort is aimed at changing the way people with pain are treated — physically and emotionally.

In 2010, the ACA charged the National Academy of Medicine (formerly the Institute of Medicine) to publish a report entitled, “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.” This report detailed the relatively primitive state of pain management health care delivery in the United States. For example, chronic pain is poorly understood, pain education in physicians is under-emphasized, and patients who have chronic pain often get suboptimal care. Rather than just highlighting the problems in pain health care delivery in America, the report specified a number of objectives to improve the state of pain health care delivery. Targeted research, funding to understand the nature of pain, creation of evidence for pain treatments, identification of resources to improve physician education, health care practitioners and other stakeholders as well as patients, and the development of patient advocacy platforms were all part of their recommendations.

GPIThe NPF, led by Daniel S. Bennett, MD, is a nonprofit organization whose mission is to transform the way pain is fundamentally understood, assessed, and treated, in line with the National Academy of Medicine’s report. One important concept promoted by the NPF is that pain is actually a collection of diseases like cancer or any other major illnesses. Furthermore, the foundation believes pain is potentially curable given sufficient research and investigation in the clinical and outcome studies. The NPF’s Global Pain Initiative was set up to educate physicians, patients, government representatives, and industry stakeholders through the publication of a series of peer-reviewed journal supplements on the current state of pain and treatment.

The Global Pain Initiative is currently producing a series of peer-reviewed publications evaluating the basic science of the pathophysiology of chronic pain as well as the evidence base for its non-surgical and surgical treatments. Once this current state of evidence is published, the NPF will incorporate the perspectives of patients who suffer from chronic pain. The integration of basic scientists, clinicians, patient advocates and corporate stakeholders will then allow for the most effective identification and appropriate prioritization of the remaining shortcomings in pain health care delivery. Once identified, these problems can be systematically addressed through several different mechanisms, such as:

  • Educating lawmakers to create compassionate and effective pain legislation;
  • Allocating National Institutes of Health (NIH) research funds to more completely understand pain and its treatments;
  • Initiating clinical trials to provide robust evidence for pain therapies; and
  • Developing public awareness campaigns to make sure patients and providers are aware of pain conditions and their treatments.

Neurosurgery has always played an important role in pain health care delivery, which is why I currently serve as organized neurosurgery’s representative within the Global Pain Initiative. It is important for neurosurgeons to maintain an active role in this process, so we can continue to provide state-of-the-art neurosurgical pain treatments for our patients.

Editor’s Note: During the month of September, we encourage everyone to join the conversation online by using the hashtag #painfacts.

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